ICIs target an integrated pathway of membrane inhibitory and stimulatory receptors (the so-called immune checkpoints), crucial for regulating T-cell activation and preventing autoimmunity and excessive inflammatory response ( Spallarossa et al., 2018). These drugs are being increasingly used for a large number of solid and hematological malignancies, also at early stages ( Moslehi et al., 2018). The clinical introduction of immune checkpoint inhibitors (ICIs) has resulted in impressive results in the treatment of some advanced and previously minimally responsive cancers ( Farkona et al., 2016). In particular, we focus on the opportunities that a baseline CV evaluation offers for subsequent management by collecting clinical and instrumental data, essential for the interpretation of troponin results, for differential diagnosis and for the formulation of a diagnostic and therapeutic workup. We herein review the main aspects of ICI-related myocarditis and suggest a practical approach. Moreover, troponins positivity should be carefully interpreted.
Troponin testing is the cornerstone of this screening, yet uncertainties remain regarding timing and candidates. Notably, myocarditis occurs within few weeks from ICIs initiation, offering opportunity for a targeted screening. Aggressive work-up and management of symptomatic patients taking ICIs is fundamental for early recognition and initiation of specific immunosuppressive therapies. In particular, several cases of ICI-related myocarditis with life-threatening course have been reported: the possibility of fulminant cases, thus, requires a high level of awareness among both oncologists and cardiologists. Cardiovascular (CV) irAEs are rare, although potentially severe. Such response, however, is not entirely tumor-specific and may result in immune-related adverse events (irAEs), involving a number of organs and systems. ICIs elicit an immune response directed against cancer cells, by targeting the so-called immune checkpoints, key regulators of the immune system that when stimulated can dampen the immune response to an immunologic stimulus. Immune-checkpoint inhibitors (ICIs) represent a successful paradigm in the treatment of cancer.
3Department of Emergency, IRCCS San Martino Policlinic Hospital, University of Genova, Genova, Italy.2Department of Internal Medicine, University of Genova, Genova, Italy.1Cardiovascular Disease Unit, IRCCS San Martino Policlinic Hospital–IRCCS Italian Cardiovascular Network, Genova, Italy.Paolo Spallarossa 1*, Matteo Sarocchi 1, Giacomo Tini 1,2, Eleonora Arboscello 3, Matteo Toma 1,2, Pietro Ameri 1,2 and Italo Porto 1,2
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